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_ _ _ _ _ _ _ �_ <br /> � <br /> A ' <br /> DATA PRIVACY ADVISORY � <br /> In accordance with Minnesota State Statute 13.04 Rights of Subjects of Data, Subd. 2, "Tennessen � <br /> warning", we would like to inform you that your request for a permit or license from the City of Orono or � <br /> any of its departments may require you to furnish certain private or confidential information. ' <br /> You are notified that: ' I <br /> i <br /> 1. � The information you furnish will be used to determine your qualification for the permit or � <br /> license requested. I <br /> 2. You may refuse to supply data, but refusal may require that the City deny the permit or I <br /> license. <br /> 3. The information may be shared with other local, state or federal agencies to the extent I <br /> necessary to process the permit or license. <br /> 4. If your requested permit or license requires Council action to approve, some information <br /> may become public. <br /> 5. You have certain rights under Minnesota State Statute 13.04 (see following page) to <br /> review private data on yourself. <br /> 6. Your full name is required to process this application or permit. <br /> 57'�� �Ev� 1� s c Nw� �Z' I� � s <br /> First Middle Last <br /> . L !b g' Qt�., �"f C�¢.. �p �. . <br /> Address <br /> M� tN w� l Ow �� �� S, 3 7V • / � � ��7•S� � a�y� <br /> City State Zip Phone <br /> I <br /> I understand my rights as ove. i <br /> � _ _._.__. _ -_.. � <br /> =_= <br /> Signature <br /> I <br /> � <br /> i <br /> Packet Last Updated.� 04/19/2013 i <br /> Page 20 of 23 <br />